Testicular Cancer

Related Subjects: |CEA |ALP |LDH

💡 With effective treatment, the overall five-year survival rate in testicular cancer is ~97%. Orchidectomy is both diagnostic and therapeutic. Discuss sperm banking early for men wishing to preserve fertility.

📖 About

• 95% of testicular cancers are primordial germ cell tumours.
• Most common solid tumour in men aged 20–40.
• In men >50, always consider testicular lymphoma.
• Seminomas – best prognosis (>90% cure).
• Choriocarcinomas – most aggressive, worst prognosis.

🧬 Aetiology

• Split into Seminomas (≈50%) and Non-seminomatous germ cell tumours (NSGCTs).
• Lymphatic drainage:
  • Right testis → interaortocaval nodes (just below right renal vein).
  • Left testis → para-aortic nodes (just below left renal vein).

⚠️ Risk Factors

• Cryptorchidism (esp. abdominal testis; risk ↓ with early orchiopexy).
• Personal/family history of testicular cancer.
• Testicular feminisation, Klinefelter’s syndrome.
• Caucasian men at higher risk.

🆚 Quick Comparison: Seminoma vs Non-Seminoma

• Seminomas: Spread later, highly radiosensitive, better prognosis, typically affect older men (30–50).
• NSGCTs: Spread earlier (often haematogenous), less radiosensitive, worse prognosis, affect younger men (15–35).

👨‍⚕️ Clinical Features

• Painless, firm intratesticular lump (must always → testicular USS in 20–40 y/o men).
• Scrotal heaviness or dull ache.
• Gynaecomastia from ↑ β-hCG (esp. choriocarcinoma, seminoma with syncytiotrophoblasts).
• Metastatic features: back pain (retroperitoneal nodes), cough/haemoptysis (lung mets), neuro symptoms (brain mets).

🔍 Investigations

• FBC, U&E, LFTs, calcium, ALP.
• Urine pregnancy test (β-hCG positive in many cases).
• Tumour markers:
  • LDH – elevated in bulk disease (prognostic marker).
  • AFP – never raised in seminoma; ↑ in NSGCTs (esp. yolk sac, embryonal).
  • β-hCG – raised in choriocarcinoma, some NSGCTs, and ~10% seminomas.
• Imaging: Scrotal USS (first-line), CXR (look for cannonball mets), CT chest/abdomen/pelvis (staging).
• ❌ Never biopsy percutaneously → risk of tumour seeding.

🧪 Histological Types

• Germ cell tumours (95%): Seminoma, Embryonal carcinoma, Yolk sac tumour, Choriocarcinoma, Teratoma, Mixed GCTs.
• Non–germ cell (rare): Leydig, Sertoli, granulosa, gonadoblastoma, stromal tumours, lymphoma.

📊 Staging

• Stage I: Confined to testis/cord.
• Stage II: Retroperitoneal node involvement (below diaphragm).
• Stage III: Distant metastases or supradiaphragmatic nodes.

💉 Treatment

• Urgent 2WW referral for any painless testicular enlargement or change in consistency.
• Radical inguinal orchidectomy (RIO): First-line in all suspected cases.
• Seminoma: Orchidectomy ± retroperitoneal radiotherapy (Stage I–II). Very radiosensitive. Chemotherapy (BEP) in advanced disease.
• Non-Seminoma: Orchidectomy + chemotherapy (BEP: Bleomycin, Etoposide, Cisplatin). Early RPLND in selected cases. Less radiosensitive.
• Prognostic factors (poor prognosis NSGCT): AFP >10,000, HCG >50,000, LDH >10× ULN, mediastinal primary, non-pulmonary visceral mets.

📑 Summary Table

📌 Less Common Tumours

📚 References

• NHS Guidelines – Testicular Cancer
• AAFP: Testicular Cancer, Diagnosis & Treatment (2018)